Cram The Pance - S1E19 Hypertension

Episode Date: April 9, 2021

Hypertension review for your Pance, Panre and Eor’s.►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!)--- Support this podcast: https://anchor.fm/scott--shapiro/supportBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

Okay, so today we're going to be going over hypertension. And as far as what the NCCPA wants you to know, that's on the blueprint, it's going to be essential or primary hypertension, secondary hypertension, as well as hypertensive emergencies and hypertensive urgency. So that's the ones we'll go over today. Now, I'm sure we're all pretty familiar with what hypertension is. It's obviously an elevated blood pressure. Let's go down and go over the two different types. There's going to be primary or essential and secondary.

Now, when it comes to primary or essential hypertension, this is going to go. going to be the one that you're going to be seeing. This is one you should be most familiar with, because this is about 95% of the different types of hypertension. It's the one you'll see most commonly. And generally, the theology for primary or essential hypertension is going to remain unclear. It's normally going to be idiopathic as far as the cause, and that's the most common cause of primary or essential hypertension is idiopathic. With that being said, there are some risk factors associated with this development that you should be familiar with. So one of those is going to be advancing age. As we get older, the vessels become calcified, stiffened, increases the pressure.

Obesity is another big one. Family history. It's actually twice as common in patients with hypertensive parents, race, in particular African American patients, high sodium diet over three grams daily, excessive alcohol intake, and then of course physical inactivity. So most of those are going to be pretty familiar things that we generally know to be known causes of hypertension or known risk factors. Now, as far as secondary hypertension, makes up only about 5% of all of the cases of hypertension. Normally, it's going to have some specific underlying identifiable cause,

which unlike in primary or essential hypertension, which was generally atiopathic, secondary is going to have some cause that we can normally treat. So the number one cause of secondary hypertension, the one that you really need to be familiar with, is going to be a renal vascular cause, specifically renal artery stenosis. That's the one you're going to see most commonly. Now, there are some other causes you should be familiar with, corotation of the aorta,

particularly when you have hypertension and a young children, you should be thinking of potentially a coerctation. Cushing syndrome, fuel chromocytoma, medications like oral contraceptives, ns, and chronic use, decongestants, particularly the ones that have pseudophedrine, and then sleep apnea are all secondary causes of hypercensensis, and then sleep apnea are all secondary causes of hypertension. Now, the one, again, the one you should really be familiar with is going to be your renal vascular causes like your renal artery stenosis, but be familiar with the other ones as well. Okay. So when it actually comes to the diagnosis of hypertension, let's go over the guidelines that you should be familiar with. The one that you're going to see most commonly is

going to be the 2017 ACC-ACH guideline. So that's the ones we'll go over today. That's the one you'll likely encounter in real life and end the boards. Okay. So, let's go down the actual blood pressures and what the as far as the 2017 guidelines state is going to be hypertension elevated etc okay so patient that has a blood pressure less than 120 and a systolic and a diastolic less than 80 is going to be considered a normal blood pressure so again blood pressure of less than 20 120 systolic and a diastolic of less than 80 diastolic that's a normal blood pressure as far as the 2017 guidelines. Now, if they have a systolic 120 to 129 and a diastolic less than 80, that's considered an elevated blood pressure, okay, this is where it gets, you know, to be more

important because those are not really that, you know, important for what you need to know. As soon as we hit 130 to 139 systolic or diastolic anywhere from 80 to 89, you're considered hypertensive. That's stage one hypertension. systolic 130 to 139 or diastolic 80 to 89. That's stage 1 hypertension. Anything 140 or higher systolic or 90 or higher diastolic that's going to be stage 2 hypertension. So really of all of those, what I think you should remember, as soon as you hit 130 or higher systolic or 80 or higher diastolic, patient's hypertensive. It doesn't really matter stage one or two, but that's as soon as you hit that number, 130 or higher, 80 or higher, they're

hypertensive. That's where you start with your stage one. So that's really what you should remember. Now, the other important thing that you need to know is that you don't just get one blood pressure reading and are diagnosed with hypertension. You actually need two separate blood pressure readings on two separate occasions of 1.30 or higher or diastolic 80 or higher to make the diagnosis of hypertension. So you need two separate blood pressure readings on two separate occasions. Okay, so that's making the diagnosis. Now let's go over some of the complications. The main complications that you're going to see in hypertension are actually related either to the cardiovascular system or the renal system. Those are the ones you'll encounter most commonly.

So when it comes to cardiovascular, you're going to see left ventricular hypertrophy, heart failure, schemic heart disease like myocardial infarctions. And it's important to know that hypertension is actually the most prevalent, modifiable risk factor for premature cardio. cardiovascular disease, even more so than diabetes, smoking, dyslipidemia. It's going to be the most prevalent, modifiable risk factor. So it's really important that once you're actually out there practicing medicine, you see patients with hypertension, you need to make sure that you treat it because you don't want them to develop cardiovascular disease.

You can treat this and prevent that. Now, as far as your kidney or your renal complications, you're going to see chronic kidney disease, end-stage renal disease. And hypertension is actually the second most common cause of end-stage renal disease. in the U.S. second only to diabetes. So again, that's really important to treat that to make sure that you prevent these things. Now, of course, there are neurologic complications like CVA, TIAs, and then retinopathy, too, that you can see, but really should be focusing on your renal and cardiovascular complications.

Those are the ones that you're going to see most commonly. Okay, so you have a patient in the office. You've made the diagnosis of hypertension. Besides, you know, initiating your lifestyle changes, your medication if you need to, they also need to be worked up. So you make the diagnosis, they need to be worked up for any potential complications or potential secondary causes of hypertension. So what are the things you need to do once you make that initial diagnosis of hypertension?

You need to do a fasting blood glucose. You need to make sure these patients aren't diabetic. Need to get a urinalysis and included in that. You want to get your urine, album, and creatine ratio. You want to make sure that these patients don't have any proteinuria, which would indicate early signs of kidney disease. You also want to get a CBC, a TSA, you want to make sure that these patients don't have hyperthyroidism, which could be another secondary cause of hypertension.

You want to get a lipid profile. You want to make sure that they don't have hyperlipidemia as well. You want to get an EKG, make sure they don't have any left ventricular hypertrophy, some of the other things we went over. Electrolites, their serum creatine, make sure. That's another way to check for any signs of kidney disease. You also want to calculate their 10-year atherosclerotic cardiovascular risk score. and then get a fundoscopy to check for any signs of retinopathy.

So those are the things you want to get initially when you diagnose them with hypertension. Now, treatment, this is the important thing. And I also want to make a note here that I'm not going to dive too deep into the pharmacologics of the medications because I'm going to make a second podcast dedicated specifically just to the hypertensive medications. But I am going to go over briefly the meds that you use in different populations and things like that. So initially you diagnose with hypertension, you want to try to implement some form of non-pharmacologic therapy. So like your lifestyle changes. It can be done initially and you can also use it in combination with medication.

But initially, if they're not extremely hypertensive, you want to try to start some lifestyle changes first before you give them medications. So what are the lifestyle changes that you want to implement in these patients? So first you want to have them lose weight if they are overweight. And actually for every two pounds of patient loses, generally the blood pressure is going to decline anywhere from 0.5 millimeters of mercury to 2 millimeters of mercury. And that's coming straight from up to date. So I'm not making that up. That's actually true, which is, and that's really significant. So weight loss is big. As far as a diet, the diet you're going to implement is something

known as the dash diet, which is known as, which stands for dietary approach to stop hypertension. It's a pretty common sense diet, but basically it's a diet that's high in fruits, veggies, whole grains, lean proteins, and low in red meat. is refined carbs. But it's a specific diet and they may ask you what diet would you implement in a hypertensive patient. It's going to be the dash diet. Exercise three to four times a week. Limit alcohol intake for men. You want to have two or less drinks a day. Women, one or less drinks for women. Dietary salt restriction. And then something that you may not be familiar with, the rest of this stuff is pretty common sense. But potassium supplementation. So patients that have

low dietary intake of potassium have actually been found to have increased blood pressure or patients that are on potassium supplementation that have normal potassium levels have been found to actually have lower blood pressure. So make sure you check their potassium levels. Of course, if they have any form of chronic kidney disease, you don't want to avoid potassium supplementation. But, you know, otherwise, potassium supplementation is important. So now moving on to pharmacologic therapy. So they failed their lifestyle changes or they're extremely hypertensive and you can't wait to implement lifestyle changes. We'll go straight to pharmacologic therapy. Now again, I'm going to make this somewhat brief just because I'm going to dedicate a second

podcast specifically to all the hypertensive medications. But if a patient does not have a compelling indication for a specific drug or class, like a diabetic patient, an African-American patient, you can actually use any one of these four classes. And there's no wrong answer here. So it's a hypertensive patient. They don't have any other complications like diabetes or they're non-African American. and you can use any one of these four classes. So those four classes are going to be ACE inhibitors. So all your prills, your licenopril, catapril, arbs, that's your anziotens and two receptor blockers,

all of your sartens, your low sartin, calcium channel blockers. Most often it's going to be dihydropyridine like amylotapine, and then your thyside type diuretic, like hydrochloratizide. So again, this is really important because if you forget anything else as far as treatment, remember this, this will get you a lot of the questions. You have a non-complicated hyperlora pretensive patient, non-African-American, any one of these four classes is correct. ACE inhibitors, ARB, calcium channel blockers, thyside type diuretics like hydrochlor thyside. You can use any one of those and it's going to be correct.

Now, let's move on to more specific, so more complicated patients or different races. Okay, so if a patient is diabetic or they have a history of chronic kidney disease, especially patients that have proteinuria, you are going to use an ACE or an ARB always. You need to know that for real life. You need to know that for the boards. That's really important because ACEs and ARBs actually slow the progression of nephropathy, diabetic nephropathy, do the effect on the efferent arterial basalilation. Don't worry about so much about the MOA. But no, anytime you have a diabetic patient or a patient with chronic kidney disease, you want to put them on an ACE or an ARB. Diabetic patients actually, even in the absence of hypertension are put on an ACE or an ARB, just because of the effect

that these medications have on slowing the progression of diabetic nephropathy. So that's really important for you to know. Okay, so that's diabetic patients, patients with chronic kidney disease, ACE or an ARP. What if you have an African-American patient? So African-American patients, you're going to stick to your thysides or your calcium channel blockers. And this is due to some studies showing decreased efficacy in drugs such as ACEs or ARPs, African-American patients. And these patients actually respond better to calcium channel blockers or a thiaside diuretic.

so African-American patient calcium channel blockers or your thioicides. You may have noticed that I didn't mention beta blockers. So beta blockers are never going to be used as your initial monotherapy unless these patients have comorbidities such as ischemic heart disease, heart failure with decreased ejection fraction. Otherwise, you don't use beta blockers as your first line monotherapy, only if they have those comorbidities such as eschemic heart disease or heart failure with a decreased ejection fraction. So those are all of your side notes. And again, let's really quickly review because that's

really important. Non-complicated non-African American patient, you can use ACEs or ARBs, your thighsides, or your calcium channel blockers. If it's a patient with a diabetic, a diabetic patient or chronic kidney disease, you're going to use your ACEs, your ARBs. And if you have an African-American patient, you're going to stick to your calcium channel blockers or your thigh zides. That's pretty much the main things you need to know as far as treatment. Again, I'm going to do a second podcast that'll go deeper into the farm side of the the hypertensive medications but that's really what you need to focus on as far as picking your meds and that'll really get you most of the questions that they're going to ask you okay now if a patient doesn't get to go with monotherapy

generally goal uh there's a few different guidelines but generally the goal for um decreasing blood pressure is going to be less than 140 over 90 if they don't get to go on monotherapy you're going to use combination therapy now combining drugs from different classes rather than just increasing the dose of the one medication that you put them on, like just doubling the dose of the single agent, actually using different classes actually shows better efficacy and less side effects. So instead of just saying, all right, we're going to double your dose of licinopro. It's better to actually add a different class like a calcium channel blocker.

It actually is more effective and it has less side effects. So that's normally what you'll do when they're not getting to go with one med, you add a second med from another class. Just a final note that you should be familiar with because I remember this coming up in a question. If you have a patient that's on like three or four different classes of anti-hypertensive agents and they're not getting to go for some reason their blood pressure is not coming down, make sure you think of secondary hypertension. That's really important. So a lot of times they'll ask you a question. Patient is not getting to go three to four different hypertensive medications.

What is the next test you should do on this patient? And likely it's going to be a renal ultrasound because you're not to go. you want to look for those renal vascular causes of secondary hypertension. So just keep that in mind. That's a little side note that may get you a question there. Okay, so that's hypertension. That's your secondary or primary or essential hypertension. Let's focus on the last thing we need to go over.

And that's hypertensive urgency and hypertensive emergency. So you have urgency and emergency. What's the difference between the two? So the only difference between the two, they both are going to be a patient that has a blood pressure, systolic blood pressure over 180. and or a diastolic blood pressure of over 120. But urgency, these patients are going to have no signs of end organ damage. An emergency is going to be patients with signs of end organ damage.

So that's the only difference. Both patients are going to have a systolic 180 or above and a diastolic and or a diastolic of over 120. But urgency, no signs of end organ damage. Emergency signs of end organ damage. So what is end organ damage and what are the signs? So what end organ damages, any of these types of symptoms. So they may have chest pain from an MI or a dissection. They may have dyspnea from pulmonary edema, congestive heart failure. They may have back pain from the dissection, the aortic dissection, number of neurologic

symptoms, headache, altered mental status seizures from an ischemic or hemorrhagic stroke, from the hypertensive encephalopathy. So any one of those symptoms are all considered end organ damage and that's going to be a hypertensive emergency. Now, so those are like the clinical manifestations. Overall, though, the most common clinical manifestation is going to be a headache. So that's the most common one that you'll see. And as soon as you have a patient with a hypertensive emergency, you want to make sure you do a number of different tests on these patients. You're going to want to do an EKG, your cardiac biomarkers, if you're suspecting an MI, CT of the head, if you suspect CVA or TIA, a CT of the chest, if you suspect,

to dissection. So there's a number of different things that these patients are going to need to be worked up for. Not really important for the vignettes, more important for real life, but just be aware that those things should be ordered in these patients when you're suspecting all of these different complications. Now, as far as treatment, for urgency, you're going to treat them normally with oral medications because you're not in a rush. Nothing's breaking down in the body. But for emergency, this is the one that you really need to know. You want to treat these patients with IV anti-hypertensive medication. Now, you may think that these patients have, you know, all of these things going on, you know, all of these signs of end organ damage, we're going to want to bring

the blood pressure down extremely fast, but that's actually not the case. And this is really important for you to know with hypertensive emergency. So when you have a patient with hypertensive emergency, these patients have, their organs have become so accustomed to this high blood pressure. They've been living with this hypertension for so long, the vascular beds of all of these organs have almost adjusted to this high blood pressure, the use to this hypertensive state. And if you decrease the pressure too quickly, these organs actually may respond in a way that leads to eschemia and damage to the organs. They may actually shut down a lot of these organs. So in these patients, you actually want to slowly lower the blood pressure. So the general rule in patients with

hypertensive emergency is going to be to decrease the mean arterial pressure. Mean arterial pressure is the average arterial pressure during a single cardiac cycle. So decrease the mean arterial pressure by 10 to 20% in the first hour and by 5 to 15% over the next 23 hours. So you're actually slowly lowering this blood pressure. Now there's some exceptions. I'm going to go over that in a minute. But generally in a patient that doesn't have any exceptions, I'll go over, the way you

want to lower the blood pressure. is going to be 10 to 20% in the first hour and 5 to 15% over the next 23 hours. Remember that. That's important. That definitely may be a question as far as lowering the blood pressure. So let's go over the exceptions. Now, there's three exceptions you need to be aware of, and they all make sense. When I go over them, you'll understand why.

So why would you not slowly lower the blood pressure over 24 hours? So these are the reasons. The patient's having an ischemic stroke, so blood's barely making through this narrowed artery, you don't actually want to decrease the pressure because that's going to lead to less blood getting through. So a patient has an ischemic stroke. There's blood barely getting through this narrowed artery. You decrease the blood pressure. You're going to have less blood going through, less profusion in the brain. So in these patients, you have some exceptions. Now, it all depends on how you're going to treat these patients. So if you have a patient with ischemic stroke,

and you've decided that they are a candidate for reperfusion therapy, so you're going to give them like thrombolytic, those clot busters like TPA, you will allow them to have a pressure up to 185 over 110 before you treat their blood pressure. Okay. So that's somebody who you're going to repurpose. Now, if they are not a candidate for repufusion therapy, you're not going to give them the thrombolyics. You're not going to give them TPA.

You can actually allow them to have their blood pressure go all the way up to 220 over 120 before you begin treatment. So that's really high, but you need to maintain that blood pressure to allow perfusion to the brain. So in a patient that is not a candidate for refusion therapy, no TPA, no thrombolytics. You're going to allow their blood pressure to get all the way to 220 over 120 before you treat the pressure. Okay.

So that's one exception, you know, that's a little bit different than what we went over. Another one is going to be a patient with an acute aortic dissection, which makes sense. You have this hole in the aorta. You're having this blood spraying out of the aorta into, you know, through this dissection. You can't wait 24 hours to lower their blood pressure. You actually have to, you know, decrease the blood pressure extremely fast. And normally the target is within 20 minutes. You want to get it down to about 100 to 120.

So acute aortic dissection, it makes sense. You can't wait 24 hours. You just don't have the time. These patients will crash and die before 24 hours have, you know, gone. So Qaeda eric dissection, you have to lower the blood pressure quickly. And then finally, for the same reason, an intrasterebral hemorrhage. Again, blood's pouring out. You don't have time.

So there's different protocols for that. So those are your three exceptions. to the rule that we would just want over over. That's 24 hours. Now, as far as the different drugs they're available, you don't need to memorize the specific drugs. I'll go over them and there, you know, there are some certain classes that use for different types of conditions. So I'll briefly go over them, but don't go too crazy memorizing all the different meds. So in a patient with hypertensive emergency, you're going to be using IV, so parental agents, IV antibiotics, IV anti-hypertensives. So the more common agents that you're going to use, and normally you'll

have a hospital protocol for this that you'll be using in real life, but the ones that you'll see commonly used are going to be nitroproside, niccaratopine, libadol, esmalol, these all have really fast onsets through IV. And nicartapine and libadol are generally used in patients with neurologic hypertensive emergencies, so stroke, hemorrhagic hypertensive encephalopathy. Those are the ones you'll see in neurologic hypertensive emergencies where beta blockers like esmol and labatol are generally going to be used in cardiovascular hypertensive emergency. So just a little side note. And again, don't go crazy memorizing those. Just be familiar with the fact that you're going to be using IV anti-hypertensive medications. All right. So that's all you really need to know for hypertension.

Again, I'm going to make a second podcast for the actual medications. Dive deeper into the farm with those things, the ADRs, the contradications and things like that. So let's just do five quick questions about what we went over today, see what you've retained. Okay, so the first question, this one's really important. In an uncomplicated non-African American patient with hypertension, which are the four drug classes you will choose from for initial monotherapy? So uncomplicated non-African American patient with hypertension, what are the four classes that you can choose from for their initial monotherapy? It's going to be your ACE inhibitors, your thighs type, your thigh side diuretics, and your calcium channel blockers. So those are the four ACEs,

Arbs, Thais-Ehytype diuretics, and calcium channel blockers. Okay, that one's really important. That's one of the ones you should really know. What is the most common cause of secondary hypertension? Most common cause of secondary hypertension. Remember, that's your renal vascular causes like renal artery stenosis. That's important too. At what blood pressure reading is stage one hypertension defined? What blood pressure reading is stage one hypertension? That's going to be a systolic of 130 to 139 or diastolic of 80 to 89. Remember that? That's like right as soon as they become hypertension, hypertensive, and that's the one you should really know. What are the two medication classes

you want to use in a patient with diabetes or chronic kidney disease? What are the two medication classes you would use in a patient with diabetes or chronic kidney disease? It's going to be your ACE inhibitors or your ARBs, your angiotensin to receptor blockers. And then finally, in a patient with hypertensive emergency, describe the rate of reduction for blood pressure over 24 hours in most patients. I'm not talking about a patient with a dissection, Schemic stroke. I'm talking about a patient with a hyper, generally patient with hypertensive emergency, most patients, what is going to be the rate of reduction for blood pressure over 24 hours? Remember, you're going to decrease the mean arterial pressure by 10 to 20%

in the first hour and an additional 5 to 15% over the next 23 hours. That's, you know, not your exceptions. That's your generally most patients, how you will treat the blood pressure over 24 hours. Okay, so thank you so much for listening to the podcast. I want to again thank everybody for the reviews. It really does mean a lot to me. I sincerely mean that. I hope this is helping. If it is, please let me know in the comments and the reviews. And good luck on your pants, your panery, your EORs, and good luck in PA school.